- Approximately 70% of patients with cancer are aged 65 and older. The number of patients with cancer over the age of 65 is projected to significantly increase over the next 20 years. The lifetime probability of developing cancer in men and women aged 70 and over is 1 in 3 and 1 in 4, respectively.
- Older patients are especially vulnerable to “over-treatment,” i.e., frail patients being provided with cancer treatment with low likelihood of benefit and high likelihood of complications toxicity, or “undertreatment,” i.e., fit older patients who are not provided with standard, evidence-based chemotherapy regimens.
- In patients age 65 and older receiving chemotherapy, geriatric assessment (GA)—the evaluation of functional status, physical performance and falls, comorbid medical conditions, depression, social activity/support, nutritional status, and cognition—should be used to identify vulnerabilities or geriatric impairments that are not routinely captured in oncology assessments. (Strong Recommendation; EB-B-H)
- While many tools are appropriate for assessment of each domain, the Expert Panel provided recommendations based on evidence supporting their utility for predicting adverse outcomes and for ease of administration. In patients aged 65 and older receiving chemotherapy, validated and practical GA-based tools can be used to predict adverse outcomes. (Moderate Recommendation; EB-B-H that GA tools predict chemotherapy toxicity and mortality; Moderate Recommendation; EB-B-M to recommend specific tools to evaluate GA domains such as function, comorbidity, depression, cognition, and nutrition.)
- The evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition.
- The Expert Panel recommends instrumental activities of daily living (IADLs) to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale (GDS) to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test (BOMC) to screen for cognitive issues, and assessment of unintentional weight loss to evaluate nutrition.
- Either the Cancer and Aging Research Group (CARG) or Chemotherapy Risk Assessment Scale for High-age patients (CRASH) tools are best utilized to obtain specific estimates on risk of chemotherapy toxicity, while short tools such as G8 or Vulnerable Elders Survey-13 (VES-13) can help predict mortality. Table 1 also provides alternatives to these options.
- Based on the best clinical opinion of the Expert Panel, clinicians should use one of the validated tools listed at ePrognosis (https://eprognosis.ucsf.edu/calculators.php) to estimate life expectancy (LE) greater than or equal to 4 years. (Strong Recommendation; IC-B-H that it predicts mortality; Weak Recommendation; IC-B-Ins that it improves outcomes or improves decision making)
- The Expert Panel especially recommends either the Schonberg or Lee Index (https://eprognosis.ucsf.edu/leeschonberg.php). The most common variables considered in these indices include age, sex, comorbidities (e.g., diabetes, chronic obstructive pulmonary disease [COPD]), functional status (e.g., activities of daily living [ADLs], IADLs, mobility), health behaviors and lifestyle factors (e.g., smoking status, body mass index), and self-reported health.
- Several indices have “presence of cancer” as a relevant variable, answering “no” to this question will allow for non-cancer LE, in order to consider competing risks of mortality.
- Delphi consensus panels of experts have established approaches for implementing GA-guided care processes in older adults with cancer. (Moderate Recommendation; IC-M)
- The Expert Panel recommends that clinicians apply the results of GA with patients to develop an integrated and individualized plan that informs treatment selection helping to estimate risks for adverse outcomes (see Recommendation 2), and to identify non-oncologic problems (e.g., see Recommendation 1) that may be amenable to intervention.
- Based on clinical experience and the results of formal expert consensus studies, the Expert Panel suggests that clinicians take into account GA results when recommending treatment, and that the information be provided to patients and caregivers to guide decision making for treatment. In addition, clinicians should implement targeted, GA-guided interventions to manage non-oncologic problems.
- Consistent with the results of formal modified Delphi consensus studies, the ASCO Expert Panel supports the specific high-priority GA-guided interventions outlined in Table 2.
Table 1. Recommended Geriatric Oncology Tools
|Assessment of the below GA domains recommended for all patients aged 65+||Recommended Tool and Score Signifying Impairment||Evidence to Support Recommendation||Administration Characteristics||Considerations and other evaluation options|
|Function||IADLs: Dependence on any task signifies impairment||Large prospective studies of older patients with cancer show IADLs predict chemotherapy toxicity, mortality, hospitalizations, and functional decline.|
Advocated by experts in Delphi consensus panels.
|Patient-reported outcome (PRO); <5 min||Consider ADLs; Any ADL deficit is utilized for characterization of frailty|
Consider objective measure of physical performance such as Short Physical Performance Battery (SPPB); Timed Up and Go (TUG), or Gait Speed
|Falls||Single item: “How many falls have you had over the last 6 months (or since the last visit)?”; one or more recent falls||Falls are common in older adults with cancer and can lead to serious injury.|
Falls have been associated with chemotherapy toxicity.
Assessment for falls is recommended by geriatric oncology expert panels and the American Geriatrics Society for all older adults
|PRO; <1 min|
|Comorbidity||Robust review of chronic medical conditions and medications through routine history: ≥3 chronic health problems or ≥1 serious health problem||Comorbidity is associated with poorer survival, chemotherapy toxicity, mortality, and hospitalizations.||Part of routine history||Consider validated tools such as CIRS-G or Charlson; history, CIRS-G, OARS comorbidity recommended by experts|
|Cognition||Mini-Cog: An abnormal test is defined by 0 words recalled OR 1-2 words recalled +abnormal clock drawing test. This a screening test for cognitive impairment and abnormal scores require further follow up and decision-making capacity assessment.|
BOMC test: A score of 6 or greater identifies patients who have moderate deficits and a cut point of 11 or greater identifies patients with severe cognitive impairment.
|Growing data show cognitive impairment is associated with poorer survival in older patients with cancer and increased chemotherapy toxicity risk.|
Mini-Cog has been shown to have high sensitivity and specificity for identifying cognitive impairment when compared to longer tools.
BOMC is practical and is included in the Cancer-Specific GA developed by Hurria et al.
|Administered; ≤5 min||Multiple tools are available for cognitive assessment.|
The Mini-Mental State Examination (MMSE) has more robust data for prediction of outcomes in older patients with cancer and has been shown to predict chemotherapy toxicity; it is included in the CRASH tool developed by Extermann et al.
The Montreal Cognitive Assessment (MOCA) is also utilized by geriatricians.
Both MMSE and MOCA are considerably longer than Mini-Cog and BOMC.
|Depression||GDS-15 item: A score of >5 suggests depression and requires follow-up.||Depression has been associated with unexpected hospitalizations, treatment tolerance, mortality, and functional decline in older adults with cancer receiving chemotherapy; these studies primarily assessed depression with the GDS.||PRO; ≤5 min||GDS recommended also by ASCO guidelines for depression.|
The Patient Health Questionnaire-9 is an alternative and is also recommended by ASCO guidelines for depression.
The Mental Health Inventory is an option and has been associated with outcomes in older patients with breast cancer.
|Nutrition||Unintentional weight loss; >10% weight loss from baseline weight; body mass index <21 kg/m²||Poor nutrition is associated with mortality in older patients with cancer.||PRO; <1 min||Consider G8 and Mini-Nutritional Assessment (MNA) as alternatives; both are associated with mortality in older patients with cancer.|
|The following tools can provide estimates of risk for chemotherapy toxicity||Items||Study Population||Administration Characteristics||Considerations|
|CARG toxicity tool: provides estimates for overall risk of grade 3-5 chemotherapy toxicity.||11 items: prior falls (1 or more vs none), hearing problems (deaf to excellent), limitations in walking one block (limited a lot, limited a little, not limited), difficulties with taking meds, interference of social activities by physical health and/or emotional problems (all of the time to none of the time) as well as age, height, weight, gender, cancer type (gastrointestinal vs genitourinary vs other), dosage (standard vs dose reduced), number of chemotherapy agents (mono vs poly), hemoglobin level, and creatinine clearance.||Patients aged 65+ with a solid tumor malignancy or lymphoma starting a new chemotherapy regimen (any-line)||PRO/Administered; 5 min|
Available online at: http://www.mycarg.org/Chemo_Toxicity_Calculator
|Can ask GA variables as part of history or include as part of PRO assessment|
|CRASH tool; provides estimates separately for risk of grade 3 hematologic and grade 3-4 non-hematologic toxicity||Assessment of risk of hematologic toxicity includes: diastolic blood pressure (>72), IADL score (<26), and lactate dehydrogenase (LDH) (>459); Assessment of risk of non-hematologic toxicity includes: Eastern Cooperative Oncology Group (ECOG)-performance status (PS), MMSE (<30), and MNA (<28); chemotherapy intensity is assessed with MAX2 index.||Patients aged 70+ years with histologically proven cancer who were starting chemotherapy||PRO/Administered; Estimated time to completion is on par with full GA (20-30 minutes)|
Available online: https://moffitt.org/for-healthcare-providers/clinical-programs-andservices/senior-adultoncology-program/senior-adult-oncologyprogram-tools
|The CRASH Scale includes GA measures known also to predict other adverse outcomes such as mortality, functional decline, and hospitalizations: IADLs, MMSE, and MNA.|
|The following screening tools have been independently associated with adverse outcomes in older patients with cancer receiving chemotherapy||Items||Study Population and Evidence||Administration characteristics||Considerations|
|G8||8 items covering appetite, weight loss, neuropsychological problems, BMI, number of medications, patient self-rated health, and age; score of ≥14 signifies impairment|
Derived from the MNA.
|Several large studies have been conducted that include patients aged 70+, which included patients with both solid and hematologic malignancies starting a new chemotherapy agent.|
G8 is independently associated with mortality (1 year and 3 years) even when controlling for ECOG PS and stage of cancer.
|Administered; 5-10 min||G8 can also be used as a screening tool to identify older patients who need more comprehensive GA.|
|VES-13||13 items including age, self-rated health, common functional tasks, and ability to complete physical activities.|
Score of ≥3 is associated with mortality and chemotherapy toxicity in older patients with cancer.
A score of ≥7 has been shown to be associated with functional decline.
|VES-13 score has been shown to be associated with mortality, chemotherapy toxicity, and functional decline.||Administered or PRO (but errors are common with PRO administration); 5-10 min||VES-13 can also be used as a screening tool to identify older patients who need more comprehensive GA|
|Consider assessment of these domains if resources available||Items||Study Population||Administration characteristics||Considerations|
|Objective physical performance: SPPB, TUG or gait speed||SPPB includes 3 tests (balance, chair stands, and gait speed); a score of ≤9 associated with increased functional decline, nursing home use, and mortality in community dwelling older adults.|
TUG measures ability for a patient to get out of chair and walk 3 meters or 10 feet and back; a score of >12 seconds associated with increased risk of falling.
|Low SPPB score associated with increased mortality in older women with gynecologic malignancies.|
TUG and gait speed have been shown to be associated with early mortality (6 months) in older patients with cancer receiving chemotherapy.
SPPB and gait speed associated with functional decline in patients with nonmetastatic breast cancer receiving chemotherapy.
|All administered; 1-5 min depending on test|